Week #7 i-Human Case Study: Evaluation of Dyspnea in
a 60-Year-Old Female Patient/WEEK #7 CASE STUDY
ACTUAL SCREENSHOT PRESENT 60 YEAR OLD FEMALE
PATIENT REASON ; SHORTNESS OF BREATH (6512 ).
WALDEN UNIVERSITY Comprehensive Case Analysis:
CHF Diagn
,
, ✅ PATIENT INTRODUCTION
A 60-year-old African American female presents to the clinic with complaints of progressive shortness
of breath (SOB) over the last few weeks. She reports that the symptoms have worsened with activity
and now occur even at rest. She also mentions swelling in her ankles and a dry cough that disturbs her
sleep.
CHIEF COMPLAINT (CC):
“I’ve been getting more short of breath, especially when walking to the mailbox. My ankles are also
swollen.”
HISTORY OF PRESENT ILLNESS (HPI):
• Onset: Gradual over the past 3 weeks
• Duration: Persistent
• Character: Dyspnea worsens with exertion and sometimes at rest. Non-productive nocturnal
cough
• Associated Symptoms: Orthopnea (uses 2 pillows), paroxysmal nocturnal dyspnea, leg swelling
• Aggravating factors: Physical activity, lying flat
• Relieving factors: Rest, elevating legs
• Timing: Worse at night
• Severity: Increasing; limits her daily activities
PAST MEDICAL HISTORY (PMH):
• Hypertension (15+ years)
• Type 2 Diabetes Mellitus
• Hyperlipidemia
• Obesity (BMI 35)
• No known history of CAD or MI
FAMILY HISTORY (FH):
• Father: Died of MI at 62
a 60-Year-Old Female Patient/WEEK #7 CASE STUDY
ACTUAL SCREENSHOT PRESENT 60 YEAR OLD FEMALE
PATIENT REASON ; SHORTNESS OF BREATH (6512 ).
WALDEN UNIVERSITY Comprehensive Case Analysis:
CHF Diagn
,
, ✅ PATIENT INTRODUCTION
A 60-year-old African American female presents to the clinic with complaints of progressive shortness
of breath (SOB) over the last few weeks. She reports that the symptoms have worsened with activity
and now occur even at rest. She also mentions swelling in her ankles and a dry cough that disturbs her
sleep.
CHIEF COMPLAINT (CC):
“I’ve been getting more short of breath, especially when walking to the mailbox. My ankles are also
swollen.”
HISTORY OF PRESENT ILLNESS (HPI):
• Onset: Gradual over the past 3 weeks
• Duration: Persistent
• Character: Dyspnea worsens with exertion and sometimes at rest. Non-productive nocturnal
cough
• Associated Symptoms: Orthopnea (uses 2 pillows), paroxysmal nocturnal dyspnea, leg swelling
• Aggravating factors: Physical activity, lying flat
• Relieving factors: Rest, elevating legs
• Timing: Worse at night
• Severity: Increasing; limits her daily activities
PAST MEDICAL HISTORY (PMH):
• Hypertension (15+ years)
• Type 2 Diabetes Mellitus
• Hyperlipidemia
• Obesity (BMI 35)
• No known history of CAD or MI
FAMILY HISTORY (FH):
• Father: Died of MI at 62
